Page 12 - When surgery alone won’t cut it - Valerie Maureen Monpellier

Chapter 1 - Introduction
Bariatric surgery has become a standard part of treatment for morbid obesity. Over 10.000 morbidly obese patients a year are treated with bariatric surgery in the Neth- erlands nowadays, and it is expected that the number of patients will continue to rise substantially 1. In general, bariatric surgery is a highly successful treatment result- ing in significant weight loss, reduction of comorbidities and improvement of patient well-being 2-4. Yet, some patients do not achieve sufficient weight loss, while others experience significant weight regain 5-7. The factors that are thought to influence the successes and failures of bariatric surgery are unknown, since they have only been studied sparsely and results have been ambiguous. It is, for example, unclear how body image and self-reported eating style affect weight loss and its maintenance. We do know, that massive weight loss causes extensive skin surplus. However, there is very little knowledge about the impact of overhanging skin on patients and how this overhanging skin possibly influences their weight course. Some authors argue that the excessive skin surplus results in extensive medical, physical and psychological problems which, in turn, might be related to weight regain in the long-term 8-12. To improve counselling before and after bariatric surgery it is important to identify which factors are related to outcome on the short as well as on the long term. In this thesis, I will focus on patient related factors and study their relationship with outcome after bariatric surgery.
OBESITY
Obesity is defined as abnormal or excessive fat accumulation that may im- pair health13. It is classified with the body mass index (BMI) defined by per- son’s weight in kilograms divided by the square of his height in meters: (kg/m2) 13. In adults a BMI ≥ 30 kg/m2 is classified as obesity; a BMI ≥ 35 kg/m2 with obesity related comorbidities or a BMI ≥ 40 kg/m2 is classified as morbid obesity 14. Obesity is a major public health issue. The worldwide prevalence has tripled since 1975, resulting in 650 million obese adults in 2016 13. In the Netherlands 14.2% of the population older then 20 year is obese and 0.9% suffers from morbid obesity 15. Obesity is associated with several medical conditions: diabetes mellitus, hyper- tension, sleep apnoea and cardiovascular disease 14,16-18. Additionally, obese patients have higher rates of cancer, overall diseases and health related mortality 19. The ad- verse health effects of obesity have resulted in increased health care use. The burden of healthcare expenditure on morbid obesity already exceeds those of smoking and a higher BMI is related to higher healthcare, medical and pharmaceutical costs 20-22.
Besides the numerous medical complications, obesity is related to extensive prob- lems of social and psychological well-being 19,23-25. Obese persons generally have a lower health related quality of life (HRQoL), more negative perceptions of their own body (i.e. a negative body image) and higher rates of psychological problems and
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